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• Unmasking the social amplification of SARS panic
  Wayne Kao
  Published on: 27 April 2016
• Use of disposable face masks for public health protection against SARS
  John H. Lange
  Published on: 27 April 2016

• Published on: 27 April 2016

  Unmasking the social amplification of SARS panic

  • Wayne Kao, Public Health Research

  Dear Editor

  After a journey to Asia during the SARS outbreak, Syed et al suggested that "the public health significance of such potent symbols as the face mask may be considered in strategies to tackle other emerging infections" [1]. Nevertheless, like other unsolved puzzles of the SARS emergence, the exact impact and lesson learned from this collective and profound symbol of masks wearing is still controversia...

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  Dear Editor

  After a journey to Asia during the SARS outbreak, Syed et al suggested that "the public health significance of such potent symbols as the face mask may be considered in strategies to tackle other emerging infections" [1]. Nevertheless, like other unsolved puzzles of the SARS emergence, the exact impact and lesson learned from this collective and profound symbol of masks wearing is still controversial.

  Face mask for SARS prevention - a significant public health strategy?

  The dramatic, somehow fearful image of people collectively wearing masks has indeed become a mighty symbol of the SARS epidemic. Syed et al indicated that "though of uncertain protective benefit, the wearing of masks may have contributed to the awareness of the collective and personal responsibility in combating infectious disease". However, firsthand experiences of SARS in affected areas seem to provide a quite different scenario. Already at the beginning of the SARS outbreak, WHO spokesman Dick Thompson warned against making the public wear face masks. He said "people buying them so they feel comfortable riding the subway doesn't make a lot of sense, we're just not going to encourage silliness because we don't want to see a shortage of masks" [2].

  In addition to competing to obtain masks with medical workers who really needed them during the crisis, having the people collectively wear masks in all kinds of non-nosocomial environments delivered a strong but exaggerated impression of the SARS risk to the public.

  This behavior was interpreted in a lay epidemiological perspective - the chance of getting infected with SARS was virtually everywhere otherwise why would random people wear masks while going to school or work, riding the metro, or leaving home for simply grocery shopping.

  The truth was that before the "mask-terror" started, fair epidemiological investigation showed that it was adequate to advise the public to keep their routines as normal as possible because people's routine life wouldn't increase the risk of SARS transmission.

  For example, in the early stage of the endemic, WHO epidemiologists maintained the view that asymptomatic transmission doesn't appear to occur [3]. People wouldn't just sit there and release SARS bugs. Canadian health officials also indicated that the chance of contracting SARS in places like Chinatowns was virtually nil [4] and urged the public to stop buying masks in fear of a possible shortage of masks in health care facilities [5].

  The risk of SARS infection was definitely limited to the close contacts with SARS symptomatic patients. The close contact, by WHO's definition, was having cared for, lived with, or had direct contact with respiratory secretions or body fluids of a suspected or probable case of SARS [6]. Therefore, the need to wear mask by the general public to reduce the risk was by all means an epidemiological misunderstanding that created enormous fear an d hysteria in Asians countries. In comparison to its counterpart Asian cities, where a mask was considered a must-have and eventually become a symbol of public horror and panic, the Canadian¡¦s transparent and epidemiology-based risk communication assessment probably made Toronto a less panic-stricken city considering that not many people were wearing masks on the streets.

  The thought "risk-is-everywhere" best portrayed by mass mask wearing fired up an extreme public panic and impaired disease control efforts in several ways.

  Forced to response to the widespread public panic induced by this dramatic and visual "mask-terror" on TV on an hourly base, every public health jurisdiction in SARS affected areas was overwhelmed with unthinkable and cumbersome tasks triggered by the infectious "mask panic". These included finding millions of facial mask in a very short period of time, calling off regular social and economic activities, mass resignation of health workers [ 7, 8], preventing the rejection of seasonal fever patients by some medical institutions in fear of SARS infection or of losing general patients who refused to visit hospitals where SARS patients had previously been found [9].

  The epidemiology of fear 'V the unlearned lesson of the SARS outbreak

  The importance of the public's reaction to an unknown outbreak or a comparable bio-terrorism attack is critical, especially because it risks creating chaos and widespread mass panic, thus crippling effective responses to the situation. The epidemiology of fear is arguably the most under-learned lesson of last years SARS crisis. Indeed, while a sudden outbreak or a bio-terrorist attack unfolds, in addition to possible biological agents, there is always another equally dreadful infectious phenomenon in the shadows - public panic. The lessons from SARS prove again that unmanaged public panic may be as alarming as the disease itself.

  Two lessons learned from Taipei, one of the epicenters of the SARS outbreak last year, reveal some of the possible mechanisms of public panic escalation and how this can be avoided.

  The leader's example effect - Taipei's costly lesson

  In a crisis, decision makers are tempted to implement draconian measures even in the absence of substantial evidence. Taipei, the last city to be removed from WHO's list of SARS affected area, exemplifies the costly lesson of risk communication within the public. When a patient who had recently visited China was reported ill and further diagnosed as a SARS probable case, leaders of the Taipei city government, including the mayor and the hea d of the health department, started wearing masks at SARS press conferences. They believed that they were thus showing their determination to combat this disease.

  Nevertheless, this political posturing of a lineup of well-known leaders wearing face masks in the city hall created an alarming image. This image, once broadcasted through the media, set off an enormous public panic in Taipei. Residents in Taipei felt that the risk of getting infected with SARS was literally everywhere. The "mask-panic" developed when Mayor Ma Ying-jiu ordered every citizen to put on a face mask when ridding the city metro and visiting city hall.

  A shocking proposal to compulsory quarantine the whole country¡'s 23 millions people for 10 days gained majority support according to a local poll [10]. This unprecedented "whole nation quarantine" was formally discussed by local politicians and influential opinion leaders. Fortunately, the outbreak faded away almost as promptly as it bloomed. This multi-billion dollar proposal didn't survive. Still, the exceptional

  magnitude of Taiwan's compulsory quarantine overwhelmed its SARS affected rivals which reflected its unparalleled mass panic rather than rational reactions. In terms of number of people quarantined per SARS patient found, Taiwan's 227 people quarantined per SARS case [11] largely outnumbered Hong-Kong's 2 to 3 people [12], Singapore's 37 people[13] and Toronto's close contacts oriented, epidemiology-based voluntary quarantine measure.

  Social amplification of the risk

  We learned from Taipei's experience that disease control measures taken by the health authority helped formulate the risk perception of SARS. The SARS corona virus was invisible, novel and hard to comprehend in a short period of time. But the initial SARS control measures were obvious and magnified in the media spotlight, which helped create the first impressions of SARS, its infection risk, and routes of transmission. The control measures implemented by the Taipei city government included spreading disinfectant on the streets, free distribution of volumes of bleach to nearly one million households, compulsory quarantine of hundreds of thousands healthy people who didn't have any known close contact with SARS patients but simply had visited the hospitals where SARS patients were later found, encouraging politicians and professional health leaders not clinically involved in SAR S patient care to wear masks in public and show this on TV, etc. All of these non-epidemiology based measures helped greatly enhance the public panic toward SARS.

  These experiences showed how important it is to respond to an outbreak with prompt epidemiological investigation for both disease containment as well as ease of the escalating public panic. Public health history has shown that in order to fail a disease control effort, health authorities can't do better than stigmatize patients, exaggerate the threat, and horrify the public with measures that have no scientific support.

  The Experiences from last year tell us that in facing an unknown outbreak, neither reacting with ignorance like the Chinese authority (SARS was officially found in Vietnam, three months after the first case had surfaced in Guangdong, China) nor responding with paranoia (like WHO's unscientific SARS travel advisory announcements which exaggerated the SARS risk and literally killed local economies) had helped to conquer SARS. The assertion "the only thing we have to fear is fear itself" has never been so accurate as during the SARS crisis. In a word, any outbreak control measure, no matter how fearsome the disease may seem to be, should be based on epidemiological evidences, not fear let alone hysteria.

  References

  1.Syed Q, Sopwith W, M Regan M, Bellis MA. Behind the mask. Journey through an epidemic: some observations of contrasting public health responses to SARS. J Epidemiol Community Health, 2003; 57: 855 - 856.

  2.Tom Cohen. Most don¡¦t need masks to stave off SARS. Associated Press. 11 April 2003.

  3.WHO. SARS 'V multi-country outbreak - Update 25. Interim report of the WHO team in China, status of the main SARS outbreaks in different countries. http://www.who.int/csr/don/2003_04_09/en/ (accessed 11 April 2003).

  4.CBC News. SARS deals Toronto economic hit. 03 April 2003; http://www.cbc.ca/stories/2003/04/03/sars$030403 (accessed 03 April 2003 )

  5.CBC British Columbia. SARS clinic ready for opening. Apr 03, 2003; http://vancouver.cbc.ca/regional/servlet/View?filename=bc_masks20030403 (accessed 10 August 2004)

  6.WHO. Case definition for surveillance of Severe Acute Respiratory Syndrome (SARS). http://www.who.int/csr/sars/casedefinition/en/

  7.BBC News UK Edition. Mass resignations of health workers in Taiwan are bringing extra pressure on the island¡¦s medical system as a record 65 new cases of SARS are reported. 27 May 2003.

  8.CBC News. Some Toronto nurses quit over SARS. 26 April 2003. http://www.cbc.ca/stories/2003/04/26/sarsnurses_030426 (accessed 10 August 2004)

  9.Next Magazine Taiwan. Nine SARS tolls undeserved, killed by the lie of the chief of municipal Ho-Ping hospital. Vol. 102. 8 May 2003. (in Chinese)

  10.Hong Shu-hui. More than 70% of the respondents agree on the implementation of whole country quarantine, according to a poll. United Daily News. 16 May 2003. http://udndata.com/library/

  11.Division of Medical and Outberk Respons, Cabitent¡¦s SARS Committee Taiwan. Report on SARS Contorl in Taiwan (in chinese)

  12.Government of the Hong Kong Special Administrative Region. Health, Welfare and Food Bureau. SARS Bulletin. 23 June 2003 http://www.info.gov.hk/dh/diseases/ap/eng/bulletin0517.pdf

  13.Sharmiipal Kaur. $2.8m paid to SARS-hit businesses, quarantine cases so far. The straits Times. 15 August 2003 http://www.sars.gov.sg/archive/

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  Conflict of Interest:
  None declared.

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• Published on: 27 April 2016

  Use of disposable face masks for public health protection against SARS

  • John H. Lange, Environmental and Occupational Consultant

  Dear Editor

  The paper by Syed et al,[1] provides observations on the use of face masks by members of the public for protection against the severe acute respiratory syndrome (SARS) coronavirus (CoV).

  The authors’ raise an important question as to whether masks are effective in preventing disease. The type of masks used can generally be categorized as either surgical or paper and are suggested to off...

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  Dear Editor

  The paper by Syed et al,[1] provides observations on the use of face masks by members of the public for protection against the severe acute respiratory syndrome (SARS) coronavirus (CoV).

  The authors’ raise an important question as to whether masks are effective in preventing disease. The type of masks used can generally be categorized as either surgical or paper and are suggested to offer similar protection. For health care workers (HCW), it has been shown [2] that masks do not provide adequate protection against SARS CoV. However, protection for HCW is somewhat different than that for those of the general public, especially those not directly exposed to droplet transmission on a “continous” basis from an infected individual. The finding of a possible dose-response [3] for exposure and infection to SARS CoV lessens the chance of infection through droplet transmission by the general public, especially when some personal protection is afforded. When masks are used along with other hygiene practices, risk of infection, excluding close contact with an infected person, like a family member, can be minimized.

  Masks have been shown to provide an increased protection rate of 2.[4] for Mycobacterium tuberculosis in comparison to no mask4. Since SARS CoV has been suggested to be spread by aerosol droplet and not to any significant degree by airborne transmission,[5] masks will probably provide some increased protection to the general public. However, as noted by Syed, it is necessary that they be properly used and changed frequently. Since this virus can survive for 72 hours or more on surfaces, its transmitted through fomite contact and infection can occur by mucus membranes (e.g. conjunctiva);[5] thus, other personal hygiene practices (e.g. hand washing) are of equal or greater importance4.

  For public health protection, use of masks can have some impact on preventing the spread of SARS CoV. However, this should be only one health practice that is encouraged by the public since others (e.g. hand washing) are also of great importance.

  References

  1. Syed Q, Sopwith W, M Regan M, Bellis MA. Behind the mask. Journey through an epidemic: some observations of contrasting public health responses to SARS. J Epidemiol Community Health, 2003; 57: 855 - 856.

  2. Lange JH. SARS and respiratory protection. Hong Kong Medical Journal 2004; 10: 392-3.

  3. Scales DC, Green K, Chan AK, Poutanen SM, Foster D, Nowak K, Raboud JM, Saskin R, Lapinsky SE, Stewart TE. Illness in intensive-care staff after brief exposure to severe acute respiratory syndrome. Emerg Infect Dis [9: 1205-10] 2003 Oct [accessed December 19, 2003]. Available from: http://www.cdc.gov/ncidod/EID/vol9no10/03-03-0525.htm

  4. Barnhart S, Sheppard L, Beaudet N, Stover B, Balmes J. Tuberculosis in health care settings and the estimated benefits of engineering controls and respiratory protection. J Occup Environ Med 1997; 39: 849-853.

  5. Centers for Disease Control and Prevention. Public health guidance for community-level preparedness and response to Severe Acute respiratory Syndrome (SARS). Draft, October, 2003; http://www.cdc.gov/ncidod/sars/sarsprepplan.htm

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  Conflict of Interest:
  None declared.

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